Chapter 7

High Risk Groups

Overview

There are groups of people who are more at risk than others. This chapter
reviews those who are known to be at greater risk and the factors that
contribute to this outcome.

Physicians

Rich and Pitts (1979) found that while suicide rates of physicians in
the U.S. were twice as high as the general population, when corrected for
age, differences disappeared. Thus, white males over 25 had a rate of 34.6
at the same time that male physicians showed a rate of 35.7.

Female physician rates present a different result. While the general
population of females over age 25 shows in 11.4 rate, female physicians
attained a rate of 40.7 Explanations based on objective data are lacking,
although speculations are usually offered based on the changing roles for
women.

Blachly (1969) identifies psychiatry, anesthesiology, and ophthalmology
as specialties at greater risk for suicide. Pediatrics are the least. Rich
& Pitts (1980) report that psychiatrists kill themselves twice as often
as other specialties and this finding is constant and statistically significant
for the years reviewed. They note as evidence that white psychiatrist suicides
reach 12% of the total number of physician commits when they represent
only 7% of the total.

Murphey (1975) notes that victims in the general population have had
contact with a physician hours to months before killing themselves and
that over half who died from overdose did so with prescriptions issued
the previous week. He concludes that the principal opportunity for prevention
occurs within the medical office when high risk people come for one last
effort to obtain help. The physicians at risk for suicide are like the
general victim, which includes an indirect call for help to their colleagues,
and especially their personal physicians. However, doctors are notoriously
poor in compliance with their own medical care (Simon, 1986), and especially
if this is aggravated by previous impairments or addiction.

Werner Simon (1986) reviews the topic of physician suicide and lists
issues that represent greater risk and therefore warning signs for occasions
of greater danger. These are :

transition from residency to independent practice

approach of retirement

when parents become terminal

when children leave home

chronic marital discord

intense competition from younger colleagues

already impaired physicians with new losses

Simon along with Murphy underscore the physicians office as the principal
opportunity to deter physician suicides.

Referral to the committee on disabled physicians as soon as possible,
in the absence of cooperation;

If substance abuse or dependencies are detected, the interventions
must be more aggressive and immediate;

referral to disabled physicians committee,

initiating a detoxification program at the same session when detected

if mild to moderate addiction, judged by lesser expected withdrawal
symptoms, care can be ambulatory and usually accomplished within one week.

if severe, with more extreme withdrawal symptoms expected, admission
to an appropriate medical unit should be initiated immediately.

Confidentiality is often raised as a reason for avoiding aggressive
treatment or hospitalization. While desirable and necessary to seek whenever
possible, it remains illusory since associates always know about the addiction
or impairment and recognize this earlier than the victim. The necessity
to initiate detoxification especially in the face of self injury risks
should not be delayed to protect privacy.

Special problems exist for the psychiatrist whose patients engage in
self injury behavior. The client-physician and indeed any, psychotherapist,
suffer special distress. For the general medical physician whose client
is a psychiatrist with a recent (1-12 month) patient suicide, there are
some special treatment issues. These are :

they need an opportunity to cartharse their feelings; simply listening
and accepting is the single most effective service and is the kind of attention
most difficult to obtain (Goldstein & Buongiorno, 1974).

reframing their distress as a form of professional grief for the losses
suffered when a client dies.

affirming that suicide is currently unpredictable, and that the base
rate for high risk clients imply a number of suicidal deaths per year per
treating unit or therapist. It is only personal vanity that supposes a
0.0 suicide rate.

help the client to form a collegial support group for survivors of
suicide attempts or commits. There are national and regional associations
of professionals for suicide prevention who may be able to fulfill this
role. There are in addition support groups for survivors of suicide who
are not identified with any profession (see resource section).

Suicide prevention is everybody's responsibility, and not only the
treating professional. No one person can prevent, nor cause another to
engage in self injury behavior. Everyone can do more to deter others.

Young

Accident and suicide in the 15-24 age class is the major causes of death
because fatal diseases are relatively infrequently. Since 1950 the suicide
rates for all American youths have been rising. The male rates have increased
from 6.7 to 20.5 between 1950 and 1980. The group at greatest risk is white
males between 20-24 with a rate of 27.8 which is nearly double that of
the 15-19 class with a rate of 15.0. Black males between 20-24 show the
highest rates 20.9 for their race, but are less than whites. black and
white females of the same age classes have remained low and consistently
below 6.0 over the last 30 years. The method of choice has shifted to firm
arms for both sexes in the younger age classes.

Seiden (1984) reviewed the issues in a Public Affairs Report (1984)
in which he stressed the role of home and family, alcohol and other drugs,
social relations & stress, academic environment and employment among
other factors. He notes the tendency to omit replacement of the father
in divorce or loss. Paffenberger et al (1966) and Stanley & Barter,
(1970) have documented the relation to adult suicide in boys suffering
loss of fathers. Others have reported that currently only 38% of children
are with their natural parents. Seiden notes the increased role of alcohol.
S. Blumenthal in her testimony (subcomm, 1985, 1985 p.53) noted that alcohol
is present in 80% of the victims who attempt suicide. Seiden also stresses
the role of loaded guns in the American homes as a facilitator of impulsive
self injury actions in youth.

Seiden concludes that "the serious problem of youth suicide has
many contributing causes, including some that will be hard to change."
He ends optimistically because "comparatively low cost but effective
techniques of interventions can save significant number of lives as well
as avert much grief and trauma" (1984).

Smith & Crawford (1986) reports a suicide attempt rate of 8.4% for
Kansas High Schools and offers data that nearly 90% did not seek medical
treatment afterwards. Their data seem to reconcile the differences reported
in rates versus percentages of attempted suicide. He confirms that conservative
estimates of attempt to commit ratios are above 100 to 1.

The range of attempt rates for the 15-19 age classs varies from a low
of 3.9% in Los Angeles (Mintz 1970). In between is 13% from Northern California
(Ross, 1986), and 10 in New York (Klagsbrun 1976). College student rates
have received more scientific and media attention than the young person
in the general population (Farnsworth, 1966). An additional subgrouping
receiving more scrutiny is the veteran, especially those from the Viet
Nam era 1964-1972 (Farberow & Williams, 1982). Bruyn & Seiden (1965)
computed the student suicide rate at UC Berkeley and controlled.

For population at risk in the state of California in 1952-1961. They
concluded that suicide rates of the college population was greater. Peck
and Schrut (1971) who had access to all coroner cases in LA country found
that the college rate for the 1960-66 period was 5.1 per 100,000 live students
per year. This was well below the general population rate. The data from
these two studies were from different times and places. These two carefully
conducted investigations document the difficulty of identifying causative
factors. Peck and Schrut suggest that larger universities usually located
in urban centers tend to have higher rates because they attract more older
men than the smaller colleges, and point towards life styles and cultural
forces in addtion to personal vulnerability. They minimize the roles of
drugs or substance abuse as explanatory factors. Peck & Schrutoffera
typical profile of the male victims they studied; "sensitive, lonely,
unhappy, ... who lacked close meaningful relations....."

Paffenberger, King, & Wing (1969) in a follow-up study of Harward
and University of Pennsylvania undergraduates during 1926-1959 identified
predictors of later suicide in physicians with data collected as students.
The average age at death was 38. The profile they constructed based on
significant differences from cohorts is limited to the times and places,
but may be useful to researchers seeking to recognize high risk students.
The fathersb were either dead or separated, college educated and professional.
The students had come from boarding schools, gave histories of smoking,
using alcohol, and dropping out of college. Current complaints at the time
of data collection were insomnia, worries, self consciousness and cyclothymic
character.

Farberow and Williams (1982) report that Viet Nam era veterans have
the highest rates of all periods of service and that the under 35 age class
from 1970-1980 have experienced the highest rates. Together they account
for 34% of all veteran suicides in this same period. This pattern reverse
the usual age distribution where the highest rates are associated with
the oldest veterans. The veteran population with the highest rates at the
young and older age classes, but dipping lower in the 35-40 ages. Farberow
and Williams note that the rates for the under 35 veterans are trending
down starting in 1979-80.

Psychological Factors in College Suicide

Rook (1959) concluded that the higher rates among college students were
associated with rigorous academic selections for Oxford and Cambridge Universities
in England. This earlier report is limited by time and location, although
it supports the more conventional argument that academic achievement is
a major stress causing the increasing suicide rates. However other factors
have been identified which play an equal if not greater role in explaining
rising suicide rates. Minnea and Rush (1981) conclude that death anxiety
is associated with preference for the right to commit and more varied justifications
for choice of suicide in people who have acknowledged self injury behavior
in the past. Boor (1976) correlated internal - external locus of control
scores with increasing national suicide rates in the US. The younger age
classes, more comparable to college age students, showed more external
scores while the older classes scored higher on internal locus of control.

Lester (1967) studied Buss-Durkee test scores which measure seven different
types of hostility in college students acknowledging suicidal considerations,
threats, attempts and no self injury ideation or behavior. Major findings
were presence of irritability and resentment score elevations in the suicidal
groups. The author concludes that there is no support for the hostility
to the self hypothesis. However, the elevated scores suggest a displaced
or repressed type of hostilities in other areas. Aside from occurrence
rates 30% of college students acknowledged suicidal thoughts in the current
year when queried by Craig and Senter (1972). Eleven Percent of counselees
at UC Berkeley came for suicidal ideation (Bruyn & Seiden, 1965). Mishra
(1982) reports that college students have greater contact with victims
before death by suicide and have therefore the greatest opportunities to
deter peer from self injury action. His sample reported 15% prior attempts
in their own histories.

Richman (1979) lists 14 points of intervention in family systems approaches
to older children and adults at high risk. These are :

an intolerance of separation.

a symbiosis without empathy.

a fixation upon childhood patterns.

a fixation upon earlier social roles.

a closed family system.

a particular pattern of dealing with aggression.

scapegoating.

sadomasochistic relationships

double blind relationships.

acting out of the bad self of the family.

a quality of family fragility.

a family depression.

communication disturbances.

an intolerance of crises.

Domino, Gibson, Poling and Westlake (1980) reported students attitudes
toward suicide. Some of their findings: 72% feel that prevention efforts
are required: 83% see suicide as a cry for help; 76% endorse the idea that
everyone thinks of suicide; only 11% see suicidal behavior as normal; Many
individuals endorsed commonly held misconceptions known as myths about
suicide. e.g. people who talk about suicide don't commit or propel who
kill themselves have made a firm decision to die. Despite all the research
and documentation of increasing suicidal behavior, a survey of 90 California
college deans or administrators by Hendrickson and Cameron (1976) yielded
a consensus that there was not a need to increase resources or deal with
this problem.

Schott & Clum (1982) studied a sample of 175 students enrolled in
an introductory psychology course at Virginia Poly Tecyh Institute. They
report support for the stress-problem solving model. Students with poor
problem solving and higher life stress are at greater risk for depression,
hopelessness and self injury behavior. Carmen & Blaine investigated
69 Harward and Radoliff students previous suicide attempts found these
followed upon the failure of defensive and coping systems in the face of
specific frustration. Important influences were loss by death or separation
in the past, versus the absence of meaningful relations in the present.

A list of significant factors is reported by Pfeffer (1982) for family
therapy with children ages 6-12, at risk of suicide: family inhibition
of change; lack of generational boundaries, severity of spouse conflict,
projection of inappropriate parental feelings onto children, and symbiotic
parent child interaction. The American Psychiatric Association has issued
a parent handout title "Facts about Teen suicide in which they urge
they list five behaviors, any two of which is sufficient to require talking
to a trusted adult or a mental health professional. These are :

* I am sleeping much later that I used to;

- I'm not sleeping well and wake up early in the morning;

- I'm beginning to take a lot of naps.

* My appetite has changed, and I've noticeably lost or gained weight.

* I feel restless

* I have withdrawn from friends and family

* I can't concentrate very well

The pamphlet notes that these should persist for two or more weeks before
construing them as signs of early depression. The latter is said to suffer
a rate of suicide equal to 15% of the victims.

While clearly intended to provide some helpful assistance, the clues
suffer from the usual problems of poor prediction. The use of this check
list will yield many false positives and cause latrogenic stigma or stress
by identifying subjects who are not at risk for self injury behavior.

Checklist of possible interventions for any school setting

1. Parents and administrators need to acknowledge that a problem exists
in order to open communication about a taboo topic. A similar failure existed
at the start of the drug era which occurred at the same time that increased
suicide rates of the young became apparent.

2.Education is helpful for adults and youth. It should focus on:

Suicide, clarifying some of the prevalent myths and provide more description
of the clinical issues;

The nature of death in current life, with emphasis on appropriate dying;

Collateral issues, such as aging, retirement, role of behavioral medicine
in facilitating coping;

3. Identify high risk students by reviewing histories, self reports
or appropriate testing in areas described below.

past self injury behavior, threats of suicide, or preoccupations with
the wish to die, regardless of lethality apparent.

Ideation expressed in favor of right to commit suicide, death wishes,
beliefs about criteria when death is preferably. Such attitudes predispose
for later self injury behavior and should be discussed in a classroom setting
as a prophylactic process.

Additional screening by psychological testing with specific procedures
to help identify high risk people for future self injury behavior. See
the section on tests for more information.

4. Students identified as at greater risk need access to more support.

Non specific counselling for identified distress at students request.

Counselling for current or past significant losses.

Peer groups with other students who have volunteered for counselling
focused on suicidal thoughts and incidents.

Family systems sessions where suicide attempts or commit have occurred
in the past, including grandparents, uncles or aunts (see the list by Richman,
1979).

Educational/counselling feedback sessions where testing results in
general, and high risk for self injury in particular, are reviewed as ways
to open up dialogue and referral as suggested by Albert, Former, and Masih,
(1973).

Focused suicide prevention classes in which high risk people receive
training or assistance in developing their own suicide prevention plans.

Letter follow-up for those resistant to accepting services has been
reported as effective in providing long term support that has measurable
effects on later suicide rates.

The increased availability of Support groups for friends and family
victims makes the postvention effort a little easier. See the support group
section for list of names and addresses.

5. Continuing education for staff with existing material on a weekly
basis until some level of proficiency is achieved and then monthly follow-ups.
One professional goal is to develop faculty capability of providing death
education courses, and lead ongoing education for the students. However,
effective suicide prevention is every employee's responsibility; conversely
all employees have some degree of grief reaction to any death. Special
debriefing sessions should be scheduled for all staff following an incident
as part of continuing education.

In this context the recent availability of a wide number of audio visual
material is expressive of the public concern and the effort being expended
to develop more and earlier educational efforts to reach into the schools
prophylactically. See the reference to audio visuals for a complete list
in this manual.

6. Psychological autopsies for staff following a suicidal incident is
helpful (attempts or verbal threats should be included). Everything else
being equal it is appropriate to include one or more students in these
conferences especially if they play a prominent role as observers or a
significant others. Selected autopsies can provide powerful educational
material for the entire student body, especially if confidentiality issues
can be resolved.

7. Peers, are in the strongest position in deter and influence other
students before they reach a point of self injury. In order to mobilize
these effectively, there needs to be a well defined faculty supervised,
but peer led support program. This requires an ongoing weekly review of
student leaders who are in resource positions such as resident counselors.

8. A suicide prevention committee is an optimal resource for developing
faculty consensus, advising the administration and providing support to
employees before during and after self injury incidents.

9. Help seeking attitudes need to be encouraged early in the year an
during the first year of academic residence. Peer support and role modeling
for these behaviors can be encouraged by orientation sessions focused on
health care and stress management co led by senior students.

Elders

People over 65 kill themselves more often then any other age group.
This and other information was made available by McIntosh (1986) in a remarkably
succinct one page summary distributed at the joint meeting at AAS &
IASP in San Francisco May 25-30, 1987. In 1983, the old were 11.7% of the
population, but 18.7% of all suicides. On average, 14 old people per day
killed themselves. It is estimated there are 200 attempts for every young
commit, but only four attempts for every old suicidal death. The older
victims are more likely to die because they use more lethal methods, have
greater intentions to die, are less likely to be rescued, and have poorer
recuperative powers when interrupted. Common features are depression which
manifest differently in the older person (Zung, 1980), physical health
problems Osgood (1982) and preoccupation somatic issues (Zemore & Eames
1979). Factors that seem to contribute are losses of significant others,
lessened importance of their roles and the effects of retirement (Osgood,
1982). The latter include reduced income, less status, purposelessness,
loss of personal control (Seligman, 1976) living alone, and increased self
dislike.

In a separate study, McIntosh and Santos (1981) report increased suicide
rates for elderly non white minorities, especially Chinese, Japanese, and
Filipino-American. McIntosh goes on to urge aggressive outreach because
the elderly rarely seek available in most communities. When coupled with
their greater risk and lethality, there is more justification for uninvited
intervention. He goes on to recommend a networking approach in which all
social resources are mobilized; e.g. neighbors, family friends, clergy,
etc. To trigger this he exhorts all parties to be aware of clinical signs
or early warning signals, and to ask directly about suicidal thinking or
planning.

This strategy is reasonable, up to a point. The reservation that needs
to be considered is the motivational differences between suicide in the
elderly when compared to the younger or the middle aged. In people over
65, suicide gets confounded with appropriate dying, death with dignity,
and the right to commit suicide, all of which impedes suicide prevention
with the elderly. For further discussion of these issues see the section
on cancer and death with dignity.

It may be helpful to distinguish high risk from acutely self injurious
people. High risk people are typically those in between suicide attempts.
Rates of those over 60 have traditionally been high. In the last 10 years,
the under 25 age group has become higher, but the senior rate remains at
the same high rate. Acute covers all ages and implies people on the verge
of action. The older group engages in more lethal methods (Weiss, 1968).
In the elderly the meaning and choice of method tends to be more specific.

High risk criteria for the elderly include people who live alone and
are male. Frazer (1985) reporting on metropolitan trends in Cayahoga county
(Ohio) among female suicide victims, notes higher rates for adolescent
and senior citizens. While the rates for single and married were proportional
to the general population, widowed were higher than divorced. Patients
with an early diagnosis of life threatening illness are also at greater
risk. Cancer patients exhibit greater rates of suicide than the general
population at risk (Marshall, Burnett, & Brasure, 1982).

A primary suicide prevention tactic for the elderly is the process of
coming to terms with death (Cutter, 1978) which yields affirmation of past
and present life. This also enhances a sense of integrity (Ericson, 1968)
which supports continuing, while permitting a readiness to die. These concepts
are elusive in clinical practice but individuals can be allowed the privilege
of acting on the assumption that death is near whether next week, next
month or next year; and that constructive use of remaining time can be
made for those who have come in terms with the inevitability of death (Cutter,
1978).

Given the universality of death, appropriate dying is strangely esoteric.
The current zeitgeist regards birth as normal and death as always due to
a pathological cause. The process of "growing down" and coming
to terms with death is no longer recognized as the usual experience of
the elderly. These growth processes have enabled the elderly of all generations
to approach death with more equanimity have happens currently (Cutter,
1978). This change is associated with the medical alterations of death
starting in the post world war II era. Death to-day comes slowly occurs
out of the home, and in unfamiliar places. The social process of dying
itself tends to be over determined by expectations and habits of the victim's
previous life style. As a result, the past adaptations to death and dying
have been disrupted by medical interventions and changes; none of which
permit a proper role for the victim in order to accomplish the "work
of dying".

Broomberg & Cassell (1983) call attention to the paternalism of
care given and requests greater autonomy for the patient. Georgotas et
al (1983) exhort more attention for affective disorders in the elderly.
However, it is not clear how ones diagnosis can be differentiated from
appropriate anticipatory grief in the elderly efforts to achieve an appropriate
death.

People in the terminal stages of any disease have unfinished business
to complete. This work consists of saying good-by, dealing with the choices
of last things, helping the survivors to continue after significant loss,
and expressing sentiments. An illustration of the latter is the example
of Jacob on his death bed giving a blessing to his children. The biblical
model assumes a knowledge that death is at hand and that the person is
ready to die.

Such a process is comforting while liberating in anyone approaching
the end stages of life threatening illness. The occurrence of a readiness
to die is not the same as wishing for death, nor does it necessarily have
to end in self injury actions. Such a readiness can facilitate patient
comfort in continuing existence either with, or without, life support efforts.
Readiness for death also permits the patient to maintain his or her dignity
and carry it over to a point of actual death. All of which document that
the nature of self injury in the elderly is different and its appropriate
prevention by health care professionals must also be different.

Health care professionals can deal with the management of self injury
behavior, by starting with the meaning of current options in the broader
context of the patient's history, values and relations to survivors. Such
a review is inherently life affirming in that the relation works both ways;
the potential survivor and the victim can share in this review and the
subsequent decisions. By doing so, they all facilitate optimism in the
work that each must do to cope with inevitable loss. The patient always
has the right to refuse treatment if deemed competent to make that choice.
Any patient can also choose to act self injuriously, regardless of rationality
or competence since the act is usually under way before discovery. The
resolution of the right to suicide controversy suggested for the elderly
is to accept the premise that it is equally erroneous to delay death as
well as to facilitate it. The recent development of societies supporting
the idea of assisted dealt are in response to the differences noted above,
and limit their scope to those with fatal diseases (Battin, 1982). The
California natural death act empowers health care personnel to respond
to the prior documented preferences of elderly patients with deteriorating
conditions. The process of completing this document facilitates a greater
sense of dignity in preparing for death. It also deters overt, impulsive,
self injury behavior.

Allowing nature to take its course is not equivalent to clinical suicide
but merely another life affirming choice that can come out of the existing
relations and life styles of the people involved. The search for death
with dignity can be supported by health professionals. The distress motivated
impulse to engage in solidarity, secretive self injury requires professional
help.

Cancer And Death With Dignity

The current literature seems to confirm the earlier report by Farberow,
Shneidman, & Leonard (1963). Commits were higher than expected in patients
with a diagnosis of malignant neoplasms. Whitlock (1978) looked for tumors
at autopsy in people age 50 and over. Those who died by suicide mode yielded
a higher occurrence of tumors than matched controls dying in other violent
modes. Louhivuori & Hakama (1979) report 1.3 and 1.9 times higher rates
for suicide in male and female cancer patients respectively, when compared
to the general population in Finland. They note that gastrointestinal cancer
patients and those with non localized tumors were at higher risk. Graves
and thomas (1981) describe results of a longitudinal study with medical
students and the Rorschach test (Maryland). They report equivalent profiles
for those who eventually succumb to cancer, suicide, and mental illness
in contrast to those wh remain healthy or develop cardiovascular adjustment
in 80 cancer patients versus 80 suicide later study (Bukberg, Penman &
Holland, 1983) on the observed prevalence of depressive states in randomly
selected cancer patients with good to excellent social support. Subjects
were 32 male and 30 female aged 23-70, hospitalized for treatment. Forty
four percent were coping well without manifest evidence of depression,
while 24% showed severe depression. The balance of the patients with good
to excellent social support. Subjects were 32 male and 30 female aged 23-70,
hospitalized for treatment. Forty four percent were coping well without
manifest evidence of depression, while 24% showed severe depression. The
balance of the patients showed moderate (18%) and some (14%). Marshall
and Burnett (1983) note that the probability of suicide in 5009 cancer
patients compared to 17,064 controls cases ranged from 50 to 100 percent
higher (New York).

A somewhat finding cases from Kinlen (1983) who followed 3440 veterinary
surgeons from graduation in 1949-1953 until 1975 (United Kingdom). He reports
a roughly two fold increase in mortality from suicide and a decreased mortality
from respiratory illness. There was no excess number of leukemia or other
cancers as might have been expected from professionals exposed to oncogenic
viruses in their work. Rutqvist (1984) studied Swedish inter current mortality
in 3857 breast cancer victims from 1961-63 and 1971-73. He notes a 21%
increase over what would be expected with excess risk of death from circulatory
disease, other tumors, accidents, suicide, injuries and infections.

These recent studies document an increased risk for suicide in patients
with cancer and especially in the first 90 days following the achievement
of a diagnosis (Olafsen, 1981). While some have argued for a "right
to suicide" under these circumstances (Humphrey, 1987) and others
for euthanasia (Euthanasia Foundation; Blachly, 1971; Wallace & Eser,
1981) those professionals committed to preventing self injury behavior
can be encouraged to seek the middle ground in assisting any patient to
achieve an appropriate death providing assistance with the real and perceived
threats to well being in the context of accepting treatment for a serious
illness.

The achievement of death and dignity

The point of departure for mental health professionals is the denial
of death found in most people. This is related in large part to the inability
of anyone to experience the moment of death and go on to report its nature.
It is only possible to observe others dying or to imagine ones own termination.
The belief systems about dying, and continuation are necessarily personal
and derived in an intellectual process. Like all beliefs it is also amenable
in an intellectual process. Like all beliefs it is also amenable to change
of efforts.

Young-Brockopp (1978) evaluated 61 adult terminal cancer patients in
the middle phase of their illness (Buffalo NY). She reports the need for
hope, honestly, and information as important, but found individual differences
in personal need to discuss feelings and aspects of death. All health disciplines
have a role to play in helping patients with serious illness achieve death
with dignity, when cure is not possible. In between they can facilitate
quality of life in accepting the impairments of a continuing illness.

This discussion reviews the issues and options from the perspective
of those wish to assist people with life threatening illness. Americans
tend to deny death in the form of alternate belief systems that support
the idea of continuing indefinitely which is exaggerated by the more recent
avoidance of natural death topics and an increased preoccupation with violent
modes of death (Cutter 1978). This is most easily observed in the public
information media which over report homicide, suicide and accident while
under reporting natural deaths. Such special attention to violent deaths
has been called the pornography of death (Gorer 1965) and in direct analogy
with the sexual repressions can induce a perverse interest in deviant sex.
Such extreme feelings about death in the US tend to get focused on cancer,
even though heart disease fatalities occur about twice as often.

Individual life styles shape the quality of death existence and in turn
influence the reactions to serious illness. These give rise to different
adjustments. Given equal severity of disease, some patients make the effects
of illness worse, while others make it better through the quality of compliance
and presence of positive thinking. The observable denial of serious illness
and especially of its life threatening aspects is a partial explanation
of how some patients aggravate their health. Such behavior has been labeled
as suicidal because of the later abuse of foods known to impair health.
The patients so observed are desirous of life, wish to stay healthy and
are compliant most of the time. However, periodically they express strong
feelings and do the forbidden such as eating food high in potassium, sodium,
excess fluids, in kidney failure or stopping insulin and increasing sugar
intake with diabetic conditions.

Oncologists are the health professionals who most often encounter patients
with a life threatening illness who fail to cooperate or frankly resist
a treatment plan that is considered optimal. The unexpected response occurs
universally, although in small numbers. Some of these reluctant clients,
go on to seek unproven methods such as laetril, coffee enemas, vitamins
only, and still other procedures. The physician encountering these clients
is perplexed, and often distressed by such lack of medical cooperation.

Understanding of this behavior can be increased if the concept of denial
is viewed in its original usual. Denial is meant to describe consciously
chosen avoidance of the unacceptable. Unconscious avoidance is called repression.
The difference is degree of control that the subject retains in choosing
to be aware or not aware of a topic. Patients who seem to deny the life
threatening nature of their cancer sometimes deliberately choose to avoid
this unpleasant topic. Other times they repress awareness of the idea.
Often the two overlap with a subsequent loss of affect which gets expressed
unpredictably. At less conscious levels there observable and measurable
awareness of he difference between denial and repression is detectable
in the residual ability to tolerate a frank discussion to bring up the
topic of death directly when it is relevant, the client can be inferred
to be repressing awareness. This assumes the professional is also able
to deal with death directly.

The denial of threat becomes problematic when it increases behavior
that impedes good health care. These are

choosing no treatment,

choosing unproven methods,

manifesting a panic state,

over reactions in terms of health habits,

excess pain behavior,

frankly psychotic behavior,

suicidal threats or self injury behavior.

This range of reactions can and does occur, but fortunately in smaller
numbers. Unfortunately, these responses to diagnosis and treatment of tumors
are frequent enough to present continuous challenge to all health professionals.
The suggested care of each of these reactions when attributable to breakdown
of denial systems, will be discussed later. All of them require increased
professional attention, best initiated by the attending physician, but
requiring the skills provided by psychotherapists.

People in conflict need assistance in accepting and managing threateing
information. When denial becomes repression, a logical or direct presentation
will not get through, or if it does, can induce a panic reaction. Patients
on the border betweendenial and repression are more difficult since they
often encourage the physician to be direct, but later they may exhibit
panic and need emergency support.

The patient with poorly managed denial is in conflict with him or her
self and is thus more vulnerable to excess stress. Some cancer patients
focus their feelings on specific objects or processes of care which then
develop into phobic reactions to their treatment; e.g. the chemotherapy
room, IV drop mechanism, the radiation therapy machine, the waiting room,
etc. Others react to somatic aspects such as sleep, pain, nausea, vomiting,
itching. and fatigue. Such distress is attributable to the medical conditions
but is often a patient over or under reactions to physical sensations when
tolerance levels decrease with experienced stress.

The general suggestion is to recognize that the patient with the most
distress is not necessarily the one with the most disease or objective
impairments. Where the denial system does not create management or unexpected
behavior there is no need to change anything. However, where personal problems,
life styles, or compliance issues begin to manifest, there is a need to
address the patient's awareness of the life threatening aspects. The more
the patient is able to review these in a neutral supportive atmosphere,
the more control can return for personal perceptions that are troubling.
Neither the diagnosis nor treatment needs to change, but rather the reactions
of the client. This takes time, and special training of those in the psycho
social areas, but the physician can appropriately start the process and
make a referral. This allows a standard or optimal medical regime to continue.

Patients repressing awareness when threats to life occur in medical
care rather than simple denial, require special assistance. The difference
may be difficult to detect, and time consuming, but the tip of the iceberg
can be notice when patients behave unusually in response to standard medical
procedures. These range from avoidance of treatment, non compliance, or
extreme reactions to changes in health habits.

1. CHOOSING NO TREATMENT

In general medical practice, failure to follow advice occurs in all
practice and is probably due to a variety of reasons. Since most patients,
most of the time do follow professional advice, the issue of non compliance
is usually noted, but not confronted. Psychological the failure to comply
with recommendations represent an inability to change habits and resistance
to new demands. In some medical conditions and with some non compliance
the resistance itself aggravates health. This has been observed most in
the management of chronic conditions much as TB in the past and diabetes
today. Psychological attention in the form of support, alternative ways
of delivering the prescriptions, and reframing of patient definitions are
helpful. Those who are not responsive demonstrate a persistence in a choice
contrary to medical advice. When time permits it is usually more constructive
to accept the actual right to refuse therapy than to break off treatment
relation. This general practice gets tested in the case of serious illness
where choice issues are exaggerated by the omnipresence of a life threatening
diagnosis.

The failure to accept treatment is most poignant in the management of
cancer, when a patient explicitly refuses an optimal treatment plan. With
truly informed consent this is simply a patient's right. If patients' find
the physician demands of therapy to excessive, they will want to choose
no therapy. Too often though, patients are influenced by stress reactions
rather than the objective sensations of illness and treatment.

The optimal approach is to help patients deal with their understanding
of issues by first resolving strong feelings, and later sorting out personal
priorities. The psychological goal here is to help patient keep control
of choice by steps that minimize the disruptive of diagnosis, treatment,
and adaptation to serious illness. For some patients the greater preference
may be to opt for nooo treatment at all. This can be positive for the overall
comfort of the patient if the following conditions are present.

the patient exhibits a great deal of effort in acquainting him or her
self with the relevant information and developing informed consent.

The prior life style, and decision making is consistent with current
reactions to medical care.

The need for control and choice are high priority items for the given
individual in contrast to the more traditional patient who accepts uncritically,
the recommendations of a trusted physician.

The positive and reassurance issue here, is keeping the patient comfortably
as the primary obligation even in the context of less than optimal treatment.

2. PATIENTS WHO CHOOSE UNPROVEN METHODS

Some patients who reject treatment options, especially in the absence
of informed consent or knowledge, go on to seek unproven methods. These
people, or their spouses, tend to be action oriented and impose great effort
or change on their environments in order to achieve significant goals before
becoming ill. In addition they seem to combine a brittle denial system
with an active problem solving approach to life. They need to be vigorous
participant controllers of their care. They may or may not be knowledgeable
about treatment procedures. The major consideration is a straw of hope
that they can invest with positive attitudes. The physician faced with
this client has limited options. The optimal one is to set a time frame
with in which standard medical care can be tried, before opting for the
unproven approach. In doing so the client's freedom to choose and wisdom
should be supported fully.

3. RATIONAL APPEARING PATENTS WHO SUDDENLY PANIC

Some patients exhibit a panic state at the first ominous sign. Others
manage well, until later, when diagnostic or treatment procedures are attempted.
While all clients will suffer increased stress the majority find ways to
manage, and do not manifest acute distress. This paragraph address those
people who show an acute, anxiety attack which represent a dramatic change
of usual demeanor. This usually manifests suddenly either all at once;
reaction. Either way the client is overwhelmed by the idea of death, and
dying in the immediate future. It is irrelevant that the objective facts
do not support this real fear.

Factual reassurance does not go far enough unless it is coordinated
with more cathartic opportunity to express the ultimate fears of death
in a sympathetic and classically non judgmental manner. This is an especially
effective attitude for the patients who are also self critical and need
approval. With this professional support the patient is ready to hear positive
facts. Often reframing the patient's perceptions of "I'm dying"
into "Living one day at a time" is extremely reassuring. Actually,
such panics are widows of opportunity to provide effective assistance to
clients who are normally to proud to admit ned of what they define as weakness.
These same attitudes persist and often impede behavioral health follow
up because of the reluctance and often impede behavioral health follow
because of the reluctance to avoid further reminders of the panic states
and "weakness".

4. PATIENTS WHO DISPLACE STRESS ONTO HEALTH HABITS

The more common paradoxical behavior for the attending physician is
the client who reports difficulties with appetite, sleep, weakness, itching,
pain, bowel, and other body processes. This becomes especially difficult
to assess when these same effect are reported as common reactions to treatment.
However, sometimes this becomes obvious as when patients describe sensations
following the second or third treatment by radiation, which usually needs
one or two weeks to manifest.

Such patients require more indirect support. The denial of life threatening
implications cannot be confronted. If patients are asked by support staff
how serious illness seems to be, they describe symptoms mentioned above,
but say nothing about the threat to life. For these clients it is more
productive to offer reassurance in the form of instructions to cope with
disrupted health habits. For example, sleep disturbances may be an over
reaction to changed patterns of aging. Providing advice and follow up to
manage sleep also provides support and reassurance which can be delivered
as a message that life is continuing. Other unexpected reactions can be
traced to repression of life threatening aspects of serious illness.

5. PAIN BEHAVIOR

Most patients with life threatening illness are normal people having
no history of psychiatric disorders. While some may be undiagnosed, the
majority are simply confronting an illness with ominous implications exaggerated
by the pornography of death. These can be treated but at the cost of some
disruptions to personal life style. In this context patients often encounter
sensations that they label as pain. The atypical patient may exhibit continuing
and extreme pain. It is important to note that the degree of pain is not
the same for different patients with the same illness.

Pain thresholds vary from person to person and from time to time in
the same person. These are further influenced by loneliness, anxiety, depression
and other medications. On the opposite side, analgesics have a diminishing
effect with the development tolerance, or a clouding of consciousness,
and a consequent reduction of quality of life, e.g. apathy, poor judgment,
discouragement, withdrawal.

The physician can enhance the management of pain by recognizing that
it is perceived and is therefore real, and also psychological in the sense
that awareness is needed to experience it. A combined approach is suggested
that emphasizes any behavioral activities within the capabilities of the
patient, with doses of medication that reduce pain without clouding awareness.
Where this is not possible, it should be frankly acknowledged that other
factors are present besides the illness which require acceptance of the
patient's preference.

6. PRIOR HISTORY OF MENTAL ILLNESS

People with histories of mental illness can also suffer from cancer.
Before the age of tranquilizers, it was observed that schizophreniacs often
had temporary remissions of psychoses with physical illness such as appendectomies,
tonsillectomies etc. Such recoveries were short lived and relapses were
universal when patients were discharged from acute physical care or entered
a convalescent stage. A similar phenomenon seems to be present when schizophreniacs
receive a diagnosis of cancer. Their bizarre or irrational behavior diminishes
and they become indistinguishable from medical patients. The explanatory
rationale is that the anxiety gets focused onto body symptoms or sensations
and thus bound, allows the psychotic person to function more like an ordinary
patient. A secondary observation is that the kindness and attention provided
by health care personnel for the psycho social needs of all cancer patients
is exactly what mentally ill people need, and it is this aspect that allows
for remission of psychiatric symptoms.

Such observations are suggestive for the medical management of encology
patients. The patients with histories of mental illness or psychotherapy
are usually no greater treatment problem than general client. It also suggests
that mental health consultation for the oncology patient is not limited
to those with psychoses. Behavioral methods are needed to manage the general
medical patient when they exhibit specific symptoms of stress such as fear
of death and somatic complaints, failures to comply, nightmares, and depressions.
Conversely, such psychological impediments to good care, usually remit
or diminish with two to four sessions of psycho social support.

7. SUICIDE

Fortunately suicide is rare. Self injury behavior is more frequent which
is usually on the order of ten to 400 times the number of observed commits.
However, the rare occurrence of suicide demands attention for two reasons.
Potential victims usually visit their physicians in the last six months
of life in what seems to be an indirect search for some kind of help with
psycho social concerns.

The second reason is that some victims of neo plastic disease prefer
suicide as a solution to the perceived inevitability of pain, suffering,
and certain death. This subjective perception of cancer is usually based
on memory of loved ones or experiences with selected others who have suffered
unusually rather than the whole range of human response to cancer. Patients
who manage illness well are not usually noticed by the lay person or current
patients.

Patients who react to diagnostic or treatment procedures with continuing
and verbalizations about self injury in their questions, or fantasies are
appropriate candidates for a direct question about their "wish to
die". This relatively benign phrase opens the door to exploring ways
in which the patient may have thought about planning for a self injury
act. Such a discussion is usually productive because it tends to delay
action by the patient. Implicit here s the notion of mixed feelings. Many
suicidal people have simultaneous wish to live and to die rather than an
all or none attitude. Any delaying tactic is life saving because it permits
people time to opt for continuing life. This practice is especially urgent
because such people are not psychiatric casualties, nor otherwise available
for prevention and support.

These suggestions are intended to give health professionals supportive
points of view when compliance issues arise in normal patients being treated
for serious illness, and especially cancer. The overall principle of keeping
the patient comfortable while nature takes its course gets impeded by mixed
feelings about pain medication. The clouding of consciousness has already
been mentioned. There is in addition the inadvertent and negative message
that death is close, and going to sleep is all that a patient has left
to do. Such a message aggravates pain, discourages hope and is contrary
to the usual optimism expressed by health care personnel. There is a remarkable
variety of time intervals between the point when health staff give up on
treatment and expiration occurs. Encouraging patients to live one day at
a time even in these extreme conditions is positive, supportive and too
often contradicted by the attitude expressed in the administration of pain
medications to a point of continuous drowsiness.

The alternative is to consider the possibility of supporting an active
role in the achievement of death with dignity through constructive tasks
such as taking care of last things, saying good bye to family, expressing
feelings of love and regret to be leaving, and perhaps even giving a positive
statement to survivors in the form of the old biblical blessing.

The preceding may not solve the controversy, but it does provide the
health professional and family members a more neutral and constructive
role in the face of life threatening illness in victims whom they wish
to assist.

Alcohol

The relation of alcohol and substance abuse to suicide behavior has
been reported in earlier reviews going back to Charles Moore (1790). Recent
evidence comes from two kinds of surveys. The first is of alcoholics and
substance abuse patients who go on to commit suicide. The second is retrospective
studies of commits for history of alcohol and substance abuse. The author
asked the SIEC to survey all articles with the key words substance abuse
and suicide. On 10/21/87, 148 citations were found. The author classified
these as either surveys of substance abuse populations (19) or suicide
and suicide attempt populations (9). The contents of each generally supported
the notion that their was increased risk of self injury behavior with substance
abuse populations who come to the attention of treatment agencies. Conversely,
there was a general finding that self injury victims who come to the attention
of health professionals are more likely to be involved in substance abuse
prior to the self injury event.

It can be conceded that alcohol and substance abuse figure prominently
in the risk for violent death in general and suicide in particular. According
to Litman (1986) it is second only to age as a predictive factor. Moore
et al (1978) used the index of potential suicide. They were able to classify
correctly, 87% of the methadone patients and 98% of normal controls. Chynoweth
(1980) describes 135 consecutive commits in the Brisbane, Australia area
and notes that 34% were drug dependent. Ryser (1983) reports a significant
increase in drug overdoses between a 1974 and 1980 samples in students
treated at emergency rooms. Fifty and 1980 samples in students treated
at emergency rooms. Fifty percent of attempters used drugs to commit suicide
or as a gesture. Clark &Compagnari (1985) studied the causative role
of death in 150 active duty service personnel in the San Diego area between
January 1983 and June 1984. Forty percent of all deaths reflected January
1983 and June 1984. Forty percent of all deaths reflected ethahol involvement.
Suicide accounted for 18% and 30% of these were legally intoxicated at
the time of death.

The most recent and definitive review of alcoholism and suicide is reported
by Ray and Linnoila (1986). The array 21 studies from 1935 to 1094 and
tabulate the number of deaths n alcoholics followed by the number and percent
of suicides among these deaths. Where available they also give the number
of years of follow-up. They note that the range varies from 2-56 percent.
Since this confounds the variable follow-up periods, the present writer
used the longest years given the reduced the total percent to an annual
basis. This yielded a smaller range; 0.23% to 11.2% commits per year in
follow up of alcoholic patients. The small number of deaths in five samples
(ranging from N=6) to N=42) suggested their remaining 9 studies with follow
up periods yielded a range from 0.23% to 3.5% with a median of 1.0% per
year for suicidal deaths among all alcoholic fatalities. The smallest rate
0.23% was found in a 22 year follow up period, and is probably not typical.
One percent per year may be regarded as high, but it is less than the 1-2%
per year reported for victims with previous attempts. The lesser occurrence
of suicidal death rate for alcoholics is consistent with lesser commit
rate for alcoholics with previous attempts when compared to non alcoholics
are examples of indirect suicide (Farberow, 1980) and seem to have a lesser
rate of commit suicide than the other high risk groups (Motto, 1980), but
probably have a lesser life expectancy if incident, homicide and natural
causes of death are added.

The Ray and Linnoila (1986) summary reflects international and probably
public supported health centers which may be less applicable to clients
in the US who are treated in privately funded health care resources. These
data show more men than women on the order of 87.4% according to the authors.
Again this reflects the sociology of who is treated in public facilities.
Women tend to drink at whom with the direct and indirect support of family
or significant others until physical termination occurs thus minimizing
the percent of suicidal deaths.

The authors go on to review biological factors in suicide and alcoholism.
For more information on this point the reader should refer to the section
on biology in this manual. They start with cerebro-spinal fluids (csf).
Lowered serotonin in the brain is the principle finding. They concluded
with the self medicating hypothesis in which the victim's addition to alcohol
is an unconscious effort to correct the imbalance. Abstinence or withdrawal
aggravates serotonin levels even further.

Depressed patients with family histories of depression had lower csf
levels of both 5-HIAA and the Notepinephrine metabolites 3-MHPG (3Methy-4hydroxyphenyglycol).

Thyroid stimulating hormone (TSH) response to Throtropic releasing hormone
(TRH) stimuli in 52 depressed females with history of violent suicide attempts
showed a lowered TSH hen compared to depressed females without violent
suicide attempts or depressed only. At five year follow up their were four
commits who had shown no TSH response earlier. Ray & Linnoila note
a negative correlation between CSF 5-HIAA and TSH response to TRH. While
interesting and potentially significant, the small samples require replication
for serious credibility.

MAO is aggravated by alcohol itself and is usually observed in severe
withdrawal manifested usually by older males with the ravages of chronic
alcoholism.

The small samples given make all conclusions extremely tentative. Their
review of the current status of alcoholism and suicide converges on the
research in "biological markers for suicide". The Ray and Linnoila
review (1986) concludes "there is a great need for further research
int the determinants of suicide among alcoholics".

The relative effectiveness of the biochemical determinants and subsequent
medications in the management of schizophrenia over the last 30 years is
a model of success for those who study depression, suicide and alcoholism.
Unfortunately the diagnostic criteria for self injury behavior is less
reliable than with the other forms of mental disorder. As detailed elsewhere
in this manual there is a need to use more agreed upon criteria for risk
estimation, lethality of methods, deliberate self harm, loss of hope, wish
to die (reason for living, intentionality, satisfaction, role of significant
losses, etc) rather than the more casual "depression" or suicide
attempt language.

Biological markers for suicide will be no more successful than psychological
predictors unless more effort is applied to precise outcome criteria for
self injury behavior as reviewed in the prediction section.

LARGER Issues

The study and treatment of alcoholism suffers from the same problems
as suicide. They both occur universally from antiquity to the present and
despite much effort there has been little gain in prevention of cure. The
definition and causes are obscure and yet consequences are far reaching.
It is quite obvious that some alcoholics commit suicide and some suicides
are alcoholic. Both populations have generated massive scientific literature
which has not as yet led to significant improvement in prevention or care.
One sign of this is the minimal attention found in textbooks of abnormal
psychology or psychiatry. Considering the universal occurrence of suicidal
behavior and alcohol addiction in clients seen by mental health services,
only one or two percent of the textbook pages are devoted to these topics.

In the clinical settings of the past, both syndromes provoked professional
anxiety, avoidance behavior, and outright hostility when either kind of
patient appeared for care. Except for specialized alcohol treatment or
suicide prevention centers the same reactions persist. Since the Suicide
Prevention Triangle (1987) manual largely focused on suicide, short review
of alcoholism may be helpful.

The early models of alcoholism assumed anxiety as the motivating source
and following psychoanalytical thinking, effort was concentrated on developing
insight, or resolving conflict as prerequisites to control of alcohol abuse.
In this view, dependence and addicting were consequence of inadequate management
of anxiety by the victim. Control would come with psychological cure. An
opposite perspective is implied in Jellinek's (1946) progressive disease
model. He starts with descriptions of behavior problems related to continued
alcohol abuse through the life cycle of the victim. His array is visible
in the drinking history scale of 52 items starting with universal behaviors
such as the first drink and culminating in more extreme or rare events
such as continuous benders or blackouts. Allergy or biological vulnerability
is the assumed causality in the AA model.

Both formulations were derived from different populations of alcohol
addiction. The anxiety model was largely derived from, and applied to,
candidates for psychotherapy with presenting neurotic syndromes and ability
to cooperate in the process. The Jellinek model was mainly based upon and
applied to the public inebriate. The relation between the two when addressed
was thought to be one of time, or degree; early for the anxiety and late
for the Jellinek model. The more appropriate dimension here would be mild,
moderate or severe alcoholism.

An addictive model is also implied in Jellinek's thinking, and comes
in terms of habituation, dependence and tolerance. Anxiety is often relieved
by alcohol in take. Social approval permits habituation. Time allows dependence.
In the career of the alcoholic, a point of tolerance occurs. It takes more
and more alcohol intake to achieve less and less degrees of release from
anxiety. Eventually, the victim and alcohol dependence can be called addicted
because of entrapment in a down hill health and social process. If left
unchecked the addict is only amenable when one of many possible consequences
becomes apparent. These are impaired health, alienated family, deteriorating
work performance, reduced income, conflict with the law, and thinking disorders
which may stimulate mental illness not usually relate to alcohol dependency.
In end stages, the victim is unable to care for details of living; food,
shelter, clothing and cleanliness are neglected.

This progression seemed to require a 5-15 year period in previous generations
(Bacon 1973). Today the alcoholic career progresses over a one to five
year cycle. Drinking patterns are more extreme and goals are to achieve
total intoxication or "black out". There seems to be some connection
with the expectations associated with the drug era, psychedelic values,
and hedonistic goals of the period when today's youth was raised.

It is now generally recognized that psychotherapy cannot begin until
substance use stops. It is less well known that often weeks or months of
treatment are necessary and deficiencies in thought, both of which make
minimal problem solving difficult enough to provoke renewed drinking.

The health professionals faced with patients addicted to alcohol and
substances with high risk for self injury behavior tends to err on the
side of suicide prevention by giving higher priorities to issues that may
facilitate suicide. This writer would advocate a higher priority to treatment
for addiction and the optimal management of the clinical sequels of the
recovery cycle which may extend through 6 to 12 months after withdrawal.
Suicide risk while continuously present is not usually acute during the
observation and support needed for effective treatment of addition. It
is in the laster months of the recovery cycle that the stressors of abstinence
may provoke self injury events.

Incarceration

Almost all the articles addressing self injury behavior in detention,
report a higher than expected level of suicide phenomenon. Whether it be
rates, percents, frequencies of attempts, commits or need for prevention,
there seems to be consensus. Table 8 gives the reader a sense of the range
and degree of suicidal phenomena for victims in detention.

The one glaring exception was a report for the NY City woman's house
of detention (Lombardi, 1979) that reported no suicides. The study was
a thesis comparing four male correctional facilities in the city of NY
to determine the significance of social climate influenced by correctional
workers. However, other studies document female rates are also elevated.
Depression is twice as high as in the general population according to Martin
& Clonninger (1985). They note that 28% of their sample committed suicide.
Climent, Plutchik, Ervin & Rollins (1977) identify significant loss
of father before the age of 10 is more highly correlated with depression
than the loss of a mother. They studied 95 female prison inmates in Mass.
Women who had made a suicide attempt had a higher overall depression based
on self report items before institutionalization. Significant items in
descending order of significance are : insomnia, sadness, overall depression,
unworthiness, emptiness, hopelessness, suicidal thoughts. Suicide attempts
were more likely in women who exhibited more violent behavior. Violence
was judged by self report, observations of correctional officers, the nature
of the crime, length of sentence, and MMPI profile (Climent & Ervin,
1972). Women judged as violent had lost both parents at an earlier age.

There seems to be further findings (Kennedy, 1984) that the inmates
at greatest risk are those housed in short term centers with rates of 57.5
versus 16-17 per 100,00 live inmates. The greatest period of risk appears
to be within the first ten days of incarceration. Topp (1979) reports highest
risk with sentences of 18 months. He also notes the period of greatest
risk is within the first few weeks of custody.

High frequency of sexual offenses and lower number of affective disorders
have been observed in victims of self injury who are incarcerated in Alaska
(Sperber & Parlour, 1984). The co-existence of these behaviors must
b viewed as co-related to some larger disorder that induces the observable
symptoms.

Deheer & Schweitzer (1985) used the victims profile reported by
the National Center for Institutions and Alternatives (Hayes, 1981) to
compare two samples of suicidal behavior. The first was a suicide watch
subgroup of 48 non attempters most of whom had verbalized a suicidal intention.
A second subgroup of 20 attempters who had engaged in self injury actions
while in custody and who had verbalized a suicide intention accompanied
with a plan of action. The authors conclude that two fold comparison with
the NICA profile held up with several small exceptions. The consensus of
findings are:

suicidal behaviors occurs within the first 24 hours,

the high risk inmate is a white, male in his twenties who would use
hanging,

their would be a higher likelihood of alcohol and drug abuse intoxication
would be present and their would be a history of both,

a history of prior suicide attempts would be present, but no previous
mental illness

the nature of the charge would not be a good indicator of suicide risk.

Hankoff (1980) identifies the elements of suicide prevention in institutions
including prisons;

systematic assessment

use of an institution wide committee to study every self injury event;

training of staff;

extended treatment for recently diagnosed affective disorders.

Complicating Factors

Factors which may complicate prevention efforts within custody are reviewed
text. Malingering is as common as the self injury problem with significant
effort expended to differentiate "serious" from "mild"
degrees of self injury; a distinction not fully tenable as noted by Deheer
& Schweitzer (1985) and confirmed by (Haycock, 1985). Risk factors
must be evaluated for the distinction to be practical (Suicide on the inside,
1976). Much of the controversy can be eliminated by evaluating degree of
lethality in the preferred method for any given victim, as discussed in
the section under measures of lethality.

Alcohol and drug abuse is a prominent concomitant of self injury behavior
(Nat'l Study of Jail Suicide, 1981). A recapitulation of these findings
is given in Jail Suicide Update (1986). 76.6% of arrests are for non violent
crimes. 30% of these involve alcohol or substance abuse charges. Almost
60% were intoxicated at the time of arrest. Fifty percent of all suicides
died in the first 24 hours of incarceration. 27% died in the first three
hours. 88% of those under the influence at the time of arrest died by suicide
in the first 48 hours. Over 50% died in the first three hours. Two out
of three inmates who died from suicide were being held in isolation.

These findings emphasize at least two significant issues for suicide
prevention. The first is the delayed effects of substance abuse on the
newly confined. Since inmates are presumptively not ingesting contraband,
the role of withdrawal symptoms exerts a larger force in subsequent depression
and or self injury impulses in the first 48 hours of incarceration. While
delirium tremens or dts may not be visible, increased suggestibility and
depression are common clinical observations, usually countered by more
sympathetic nursing and/or withdrawal medications. The second is the aggravating
role of isolation in facilitating suicides. The traditional use of isolation
is to deter suicide with removal of methods and provision of supervision.
Detention centers do not usually provide the necessary supervision nor
the sympathetic nursing, coupled with the greater vulnerability the combination
can explain increased suicides.

Cox, Paulus, & McCain (1984) reviewed archival records from four
state prisons in Illinois, Mississippi, Oklahoma, and Texas from 1952-1980.
They report increased pathology with increased crowding. They cite increased
violent and non violent deaths, psychiatric commitments, attempted suicide,
and self mutilation. They conclude that the primary causes of the observed
negative effects related to crowding may be due to cognitive strain, anxiety,
fear, or frustration.

Four factors were identified by Gaston (1981) as occurring more often
in inmates of a prison. These are addiction, depression, poor reality testing,
and poor impulse control. Jail Suicide (Hayes, 1987) adds: talking about
suicide, previous attempts, hopelessness, helplessness, unrealistic plans
for the future, preoccupied with the past, ineffectual with the present,
difficult with others. Many of these are associated with recovery behavior
during the first 30 days following detoxification.

Voluntarism (Straffer 1983) is the process of giving up existing "rights"
in order to hasten early execution for criminals convicted of homicides.
This is relatively rare, but yet occurs often enough to raise questions
about its role in contributing to homicide. The author construes this behavior
as suicidal.

There is also an ethnic factor to consider for those who commit or attempt
suicide in prisons. McCain (1983) reports that medical deaths in those
under 45 occur more often in black and non-hispanics compared to the same
groups in the community. Copeland (1984) looked at inmates of Dada County
Florida detention centers. He reports that most suicides occur in white,
younger inmates and tend to be by hanging. The author relates the occurrence
of suicide to the degree of supervision provided by the correctional staff.
Anson & Cole (1984) confirm. Anson (1983) notes ethnicity and suicide
trends in the state prison system of the US. He argues for the use of percentages
of ethnic populations to the total in assessing suicide rates or percentages
in the incarcerated. He does this by using data available in the 1981 source
book of Criminal Justice Statistics published by the U S Department of
Justice. He found the number of inmates classified by ethnic status in
51prison systems, including the District of Columbia. With 84 completed
suicides he computed rates of commits by all inmates for each prison and
compared these to ethnic percentages of the total population confined.
Anson computed correlation coefficients for both but analyzed them separately
by institutions for high, medium and low numbers of inmate populations.

Anson found that for high population prisons:

an inverse relation between the proportion of black inmates and the
rate of suicide,

a direct relation between the proportion of white inmates and the rate
of suicide,

no relation for other minorities (Indian, Orientals, & Hispanics).

These relation do not obtain in smaller prisons, and the black relation
reverses in the medium size prisons.

The literature of the last ten years continues a negative view of the
effects of incarceration on suicide risk. Confinement seems to provide
significant stress on vulnerable victims. The situation aggravates the
dangers by inadequate psychological care in a context of priority for detention
and the use of isolation for suicidal inmates.

Homosexualities

There is a general expectation in the public perception that self injury
behavior occurs more often among the homosexual population. Rofes (1983)
discusses the issues under a provocative title that reflects contemporary
attitudes to homosexuality. However, data on this idea is lacking, or when
it is elicited suffers from highly selected or volunteer samples which
do not reflect all homosexually oriented people. Precision is also lacking
as to what is implied by homosexuality. The range of possibilities goes
from a one time sexual encounter to exclusive same sex orgasms. In between
are men and women who have tried both sexes one or more times (Kinsey et
al 1949). Still others belong to the homophile population with none or
minimal sexual activities (Motto, 1985). The research situation resembles
the same difficulties as with suicide.

Homosexuality has existed from antiquity with variations in tolerance
by the larger community. While there is no immediate threat to life, there
is stigmatization of people perceived as engaging in homosexual behavior.
One significant change is the recent evaluation from a state of abnormally
to one of relatively normal choice in sexual orientation (APA, 1987).

Saunders and Valente (1987) reviewed the risk factors in lesbian and
gay men for suicidal behavior. They conclude that male and female homosexuals
are linked to increased rates. They based this on several sources. They
cite "three large well designed studies that found a significant link
between suicide attempts and gay and lesbians". They cite Saghir,
et al (1970a & b) who are described more fully below. Saunders &
Valence note that subsequent researchers (Bell & Weinberg, 1978; Jay
& Young, 1979) report a increased presence of high risk factors including
30% more alcohol abuse. Saunders & Valente site a significantly higher
rate of alcohol abuse, suicide behavior, and interrupted social ties, all
of which are linked to suicide mortality. They note that these studies
are not based on direct evaluation of gay men and lesbians and caution
that membership in a high risk group does not make every individual a suicidal
victim.

Martin (1985) followed 500 psychiatric outpatients for six to twelve
years. Death from natural causes was 1 1/3 times more likely than expected
but not significant. Unnatural death was 3 1/2 times more likely than expected.
Suicide and homicide were particularly high. Initial diagnoses predictive
of unnatural death included alcoholism, antisocial personalities, drug
addiction, and homosexuality.

Harry (1983) studied four samples of homosexual men and women in San
Francisco. The data supported the hypotheses of gender role non conformity
during childhood associated with social isolation. The latter is related
to subsequent suicidal feelings and attempts. However, men were more vulnerable
than women in subsequent suicidality.

Hendin (1982) reviewed the scientific literature in a chapter on homosexuality
and also suggests that there does exist evidence for an increased risk
of self injury behavior, both attempts and commits. He bases this on earlier
studies that are generally small samples, with black and white races of
both sexes. The one exception he cites is the Saghir et al study (1970).

Saghir, Robins, Walbran, & Gentry (1970a & b) are cited by the
previous authors and are worthy of a fuller description even though their
research occurred twenty years ago. Their subjects were cooperating homophiles
in the St Louis area. These subjects were homosexual male (n=89) and female
(n=57) who were compared to heterosexual male (n=35) and female (n=45).
All subjects were single volunteers. The percentage of suicide attempts
reported for females were 23% and 5%for homosexual and homosexual orientations,
respectively. The difference between homophile and heterosexuals were statistically
significant for the females but not for the males. Emotional disorders
were slightly greater than in the heterosexuals, but alcohol, and substance
abuse histories were significantly greater in the homophiles. The prior
attempts were of minimal lethality and do not reflect the higher lethality
attempts or commits.

The current status of the research with homosexuals and suicide confirms
that they represent a high risk group, but the motives, causality and predictability
of future self injuries remains as enigmatic as with other identified higher
risk populations.

Black Suicide

The literature between 1977 through 1987 reflects a continuing concern
about the ways in which black suicide is different than white and factors
that might explain the lack of equivalence. The peak years for black suicide
in men continues to be the 20s (Davis, 1070) in contrast in white suicide
which increased directly with age. Rates in those under 35 are now equal
for blacks and whites men. Female blacks show lower rates in all regions
of the US while black men show an increase in the NE and South (Davis,
1979a). Loss of Love object (Datel & Jones 1982) or relations (Bush
1978) and weakening of family and communical ties are reported as contributing
factors in black suicide. The situations for black youth continues to grow
worse judged by factors correlated with suicide rates. Thus rates of unemployment,
delinquency, substance abuse, teen-age pregnancy, and suicides are higher
(Gibbs, 1984).

There is little variation by race but wide differences in socioeconomic
variables for a suicide potential score devised by Wenz (1978) using census
tract infrormation for a northern city. Sotuh (1984) tracked post world
war two differences in black and white suicide rates. These were related
to the declining racial income inequality. He concludes that the changes
are correlated with an explanation based on non white suicide rates moving
higher, i.e. towards the level of white suicide rates.

There was support for the hypothesis that suicide attempts would occur
more often in a population where black consciousness would be lower (Kirk
& Bucher, 1979). There was partial support for additional hypotheses
that group cohesiveness was lower and depression higher in the same sample.
The sample was based on inner city, young adult black males with suicide
attempts in the previous six months and matched controls.

Vargas (1982) studied bereavement in survivors where victims died in
one of four modes of death. Subjects were recruited from the metropolitan
Los Angeles and consisted of white, black and hispanics females, with approximately
25% additional males. Data was analyzed for the total and for females only.
After careful screening for comparability 66 white, 70 black and 65 Hispanic
survivors were studied. The author concludes that mode of death and ethnicity
of survivor influenced the degree of bereavement. More specifically, while
all exhibited emotions o bereavement Hispanic females suffered the greatest
measurable grief from homicide victims, and second most from accidental
deaths. The lest grief was observed in black and white females who survived
victims of natural and suicidal deaths. These findings suggest that the
emotions of bereavement are more than a situational depresson and are shaped
by the culture of the ethnic group survived.

Martin (1984) reports an inverse relation between suicide rates for
race and church attendance by ethnic subpopulations in 1972 to 1948. The
annual suicide rates of black, white, male and female subpopulations moved
inversely to the same annual figures for church attendance. The author
construes this as evidence for the prevention effects of religiosity.

Howze (1977) made in depth clinical study of 13 black women who attempted
suicide and attributed their self injury behavior to early and irreversible
losses to self esteem and security when they were children. As adults they
felt frustrated, guilty, and acted out aggressive impulses.

Convulsive disorders

The scientific literature before 1980 was reviewed by Mathews and Barabas
in 1981 and supports the estimate epileptic suicide rates being about four
times as high as the general population (1981). The last ten years of suicidology
literature continues to report higher suicide rates (Barraclough, 1981),
and the use of anti-seizure medications for suicide attempts (McKay, 1979,
Hawton, Fagg, & Marsack 1980). Brent (1986) reports data that supports

an increased risk for suicidal behavior in children with epilepsy,

greater lethality of suicide attempts with greater intent present,
and

these attempts are associated with the use of phenobarbital as an anticonvulsant.

An overview in the British Medical Journal notes that the suicide rate
is four, five or seven times that of the general population depending on
the study (1980). Higher risk is attributed to difficulties with housing,
schooling, employment, social relations, psychiatric disturbances, and
anticonvulsant drugs. The risk can be lessened by education, watching for
psychiatric disturbances and monitoring the amounts of drugs prescribed
for epileptics according to this articles.

Mittan, Locke & Gatica (1983) report more suicidal thoughts and
impulses and higher risk factors for suicide in three samples of epileptics
studied in Metropolitan Los Angeles. They tested 193 urban whites, 116
urban blacks, and 89 urban Latinos who were being treated at the Sepulveda
VAMC, Martin L King Hospital, and Harbor General Hospital. They conclude
that the combnation of depression and hostility was more prevalent in their
samples than in normal individuals. An unexpected finding was the significant
role played by patient fears about seizures in actual suicide attempts
and reasons for their suicidal impulses and fantasies. Mathews and Barabas
(1981) reviewed the literature and while confirming the preceding added
the following:
Robertson & Trimble also reviewed the literature on depressive illness
& epilepsy (1983).

Incarceration suicide among epileptics is especially high and specifically
in combination with depressive diagnoses. Gunn (1974) obtained social class,
occupational, and family background data from 158 epileptic prisoners,
66 hospitalized epileptics, and 180 non-epileptic prisoners. The epileptic
prisoners exhibited a greater degree of depressive and suicidal pathology,
especially in terms of drinking behavior.

Roy (1977) compared 17 patients with hysterical fits, previously diagnosed
and treated by neurologists as epileptics, and a matched control group
of 17 epileptics. They were differentiated by five factors: a family history
and personal history of psychiatric disorders, attempted suicide, sexual
maladjustment, and a current affective syndrome.

Stewart and Lovitt (1982) addressed the differential diagnosis of hysterical
seizures by a double blind methodology using psychological tests with three
defined groups: organic (neurological) seizures alone, (N=11), organic
(neurogenic) and psychogenic (hysterical), those with purely psychogenic
seizures (N=13). The tests used were: the schedule for affective disorders
and schizophrenia-life time version (SADS-L), in conjunction with the DSMIIR
and the RDC to establish psychiatric diagnoses. Other tests were the WAIS,
the Bender-Gestalt, the MMPI and the Rorschach.

Significant differences were found. Patients with neurogenic (organic)
seizures were found to have alcoholism, anxiety disorder, and minor affective
disorders. Patients with mixed and psychogenic seizures had more severe
psychopathology including major affective disorders and major character
pathology. Patients with mixed and psychogenic seizures also had a markedly
higher incidence of suicide attempts and past history psychiatric treatment.
The authors excluded temporal lobe epilepsy patients.

The literature includes treatment approaches as different as art therapy
(Naitove, 1983) and partial amygdalectomy (Mempel, 1971) with beneficial
effects reported by both authors on relatively small samples.

The review is somewhat disappointing because of the lack of publications
dealing with this topic. This may be an artefact of underfunding or lesser
priority in editorial policies. Either way it documents an insufficient
attention to a significant source of self injury behavior.

Summary

This chapter has reviewed the subgroups known to be at higher risk for
death suicide. The group at highest risk seems to be those over 65. Youth
suicide has increased dramatically since 1958, but is not as extreme as
the elderly. In between are the deaths of the new incarcerated, especially
the short term prisoners in detention centers. Along the way, are the equally
tragic, but less frequent subgroups of female physicians, young blacks,
homosexuals, convulsive disorders, victims of alcohol dependence, cancer,
aids, borderline personality, and the native Americans.